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• We have 2 locations to serve you better:
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• 1310 Greene Ave., Suite 760,
  Westmount, Qc., H3Z 2B2
  (514) 515-9350 or
  (514) 937-1228 (ext. 21)
• Queen Elizabeth Health Complex
  2100 Marlowe
  Suite 626
  Montreal, Qc, H4A 3L6
  (514) 482-3327

Appointment Form

Intake Date
*First Name	*Last Name
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Date of Birth
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*Email
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Address
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Language
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*Request For
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*Employment	Occupation
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Couples (optional)
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Marital Status
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Referral Source
*In Current Psychological/Psychiatric Treatment
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*Previous Psychological Treatment
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Please provide a brief description of the current presenting issue and any other information to help us match you with a suitable professional:
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